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The Going Global blog is an opportunity for emergency physicians to share their experiences practicing and teaching outside the United States. Submit an article about your experience to EMN at emn@lww.com. Be sure to include a brief biography and photographs of the authors. Photos taken during time spent abroad are also welcome, and should be 300 dpi and in jpg, tif, or gif format.

This blog was started by the emergency medicine residents of Palmetto Health Richland in Columbia, SC, who travel the globe on medical missions. The program is under the direction of Thomas Cook, MD, who oversees one of more than 40 academic departments of emergency medicine that sponsors Global International Emergency Medicine Fellowships.

Monday, July 15, 2013

A Mission to One of the Most Devastated Places in the World

By Josh Skaggs, MD

I went on a medical mission to East Africa’s South Sudan this past January and February. The country is one of the most undeveloped, isolated, and devastated places in the world, and it was an amazing experience even though being there was incredibly tough.

South Sudan and Sudan used to be under the control of Egypt, and were overseen by Great Britain. Great Britain withdrew from Sudan, its former colony, in 1956. Sudan had two regions at that time, the Arab north and the tribal south. War broke out after the northern Sudanese government began killing all non-Arabs in the south who would not “convert” to Islam. The south subsequently formed an autonomous region to protect itself. Multiple wars continued through the decades until South Sudan seceded from the north and established its own country in 2011. Unfortunately, fighting still continues in the disputed border area between the north and south. Not only has civil war decimated this country, but Islamic militias known as Janjaweed, invading from neighboring Arab countries and deriving support from the northern Sudanese government, have killed hundreds of thousands of the indigenous black Africans in the Darfur region in the west. Various rebel groups such as the Lord’s Resistance Army (LRA) also have invaded from neighboring countries to take rob and enslave the local populace.

South Sudan is one of the least developed countries in the world because of decades of civil war and ongoing corruption. It has the highest per capita rate of human trafficking and slavery. An estimated two million people have been killed over the past decade, and four million people have been captured and forced into slavery, predominately in North Sudan. The former Sudan was almost one-quarter the size of the United States, and South Sudan today has fewer than 25 miles of paved roads, very few schools, and hospitals that are hospitals in name only.

Prior to starting this medical mission, I was able to swing by Ethiopia for a few days and visit my dad, stepmom, and little brother, who live in Addis Ababa. I was also able to take a helicopter trip with my dad to the lowland area of Ethiopia to visit some isolated tribes with whom he was working. An American pediatrician accompanied us as well, and brought some basic wound care supplies and medicines for any medical cases that we might encounter.

I left for South Sudan after a few days in Ethiopia, and getting in is a struggle. The only way to get into the country is through Ethiopia or Kenya, and the only paved runway in the country is in the capital, Juba. Our team flew in on two separate flights, and we had to make three different stops on the way to refuel our single-engine prop plane. We were greeted by some soldiers who examined our bags by dropping them on the ground from a few feet up in the air. I guess they thought they would be able to tell if we were carrying explosives or weapons if the bag exploded!

I traveled with a Christian group called Make Way Partners (MWP) that rescues children, typically in developing countries who are at a high risk for slavery or death. The organization was started after the founders, who were missionaries in Spain, came across large groups of young children in Portugal who were held hostage for sex slavery. MWP got involved in South Sudan because of the large number of orphans there, many of whom have died because of a lack of food and shelter. Literally hundreds of orphans in one region in South Sudan have been killed by hyenas at night. MWP has founded four orphanages in South Sudan, with each taking care of several hundred kids.

South Sudan has huge numbers of orphans, largely because the decades-long civil war has wiped out a large percentage of the middle-aged and elderly. Diseases such as AIDS, TB, and meningitis have ravaged the population, and the absolute lack of health care has created many orphans as well. Sometimes parents will not be able to feed all their children and will have to decide which one to abandon to keep the rest alive. Many children have also been kidnapped and sold into slavery from the South into the Arab North. Even if these children are able to get free and return home, they are seen as a disgrace and the families will not take them back.

Typically, the doctors and nurses in the group would work in the clinic all day and then play soccer or volleyball with the orphans in the evening. The kids were amazing, despite some absolutely awful stories from them about watching their parents and siblings be killed in front of them. They were some of the most loving and fun children to be around. They loved attention, and you couldn’t walk more than a few steps anywhere outside without a young kid running up to you, grabbing your hand, and walking with you. Often I would walk back from the clinic with four or five kids all holding my hand at once.

Our living conditions at the orphanage were sparse. There were barely enough rooms and bunkbeds for the orphans themselves, so we slept in the tents outside so we did not intrude. Our first week was in the south of the country in Torit, and it was brutally hot — the temperature hovered around 110°. Week two was in the northern part of the country in Nyamlell, which is the edge of the Sahara desert. Temperatures could climb as high as 120° there.

This is where we slept.

We filtered water by diffusing it through a clay pot.

Our bucket showers.

We had a truck that would bring in our water from the local river. Surrounding villages had to rely on a donkey for transport.

We saw patients out of a clinic attached to the orphanage. It had no diagnostic equipment other than a rapid diagnostic test for Malaria falciparum, which was actually quite handy. A drop of blood in the device, apply a reagent, and have a positive or negative test result back in five minutes. We did, however, have a very well stocked pharmacy.

South Sudan has one of the highest infant mortality rates in the world, according the CIA factbook, getting narrowly edged out by countries like Afghanistan and Somalia. I heard the entire country had only one ObGyn, who was located in the capital. Caesarean sections are obviously hard to come by, and they seem to engage in some incredibly shoddy local practices related to childbirth. After the umbilical cord is cut, for example, feces are rubbed into the umbilical stump. You really have to beat some serious odds to live to the age of 5. Typically in South Sudan midwives are in charge of certain regions, and they will come to deliver a baby. One of the things we tried to do was get together with the local midwives several times during our stay. We wanted to educate them about the delivery process — what to do and not to do.

Regional hospitals are spread throughout the country, and are staffed by people who simply don’t have the training or the support to be able to take care of the many sick patients they see. The hospital I visited had a couple primary care doctors who acted as internists, surgeons, ObGyns — you name it. The patient’s family members had to supply the patients with food, clean them, take care of them, and purchase medications if they were prescribed (if they were even available).

A general ward in the local hospital.

The hospitals don’t have ventilators, electricity (except when generators run for a few hours in the evening), or general anesthesia. Operations are done using regional or local anesthesia.

This patient likely had visceral leishmaniasis, and he was dying. My fingers are palpating the edge of his spleen.

This child had what I believe was atopic dermatitis. He had it so badly that his eyelids were contracted, keeping him from being able to blink. He was developing corneal clouding already because of this.

We saw lots of tumors. This growth on this patient’s knee had been there 10 years, had not changed in size, and was not bothering her. It was quite firm, maybe a calcified suprapatellar bursa.

The growth on this woman’s arm had significantly increased in size recently, and was thought to be malignant.

Tons of kids had burns from being around cooking fires in their homes.

Onchocerciasis: river blindness.

Another common cause of blindness is trachoma, an easily treatable disease that causes the eyelids to invert, and then scratch and ultimately scar the cornea. Here you can see an entropion secondary to Chlamydia trachomatis.

Pott’s disease secondary to extrapulmonary tuberculosis.

Thought to be secondary syphilitic lesions.

This woman’s conjunctiva was pure white. Her hemoglobin had to be around 2. She was so weak she couldn’t walk without assistance. She was having dark stools, and likely had a chronic GI bleed from hookworm. No blood transfusions are available in South Sudan outside the capital, so I treated her parasites, gave her vitamin C and iron supplements, and had her drink fluids. That was all we could do.

Enteric worm.

So many people in South Sudan were malnourished. One of our responsibilities was to check kids’ mid-upper arm circumference, weigh them, and report it to the local health authority if they were severely malnourished. Unfortunately, the local health district/hospital didn’t have any nutrition supplements to feed kids that were starving in front of them.

A lot of the kids had Kwashiorkor syndrome as well as hair color changes because of protein and nutritional deficiencies.

This child developed lesions a couple days before I saw him. I treated him for a staph infection.

Here’s another sad case of a child who had a history of epilepsy. She had a seizure, and her foot fell into the fire while seizing. Not only did she have a badly burned foot with exposed bone, but the village ostracized her for her epilepsy because they thought she was under a curse. She obviously had a lot of trouble getting around, and we gave her a chair to put in front of her because we didn’t have crutches.

Dr. Carol, an American surgeon from Alabama who lives and works in Kenya, and Dr. Seno, a Kenyan doctor who is doing a surgical residency under Dr. Carol, both came on the trip. They were absolutely fantastic people. Here they are amputating a gangrenous digit under the trees outside the clinic.

Carol and Seno operated on a child who self-circumcised with his fingernails because other kids were making fun of his foreskin. His penis was badly macerated and infected, but he ended up having a good outcome.

People would begin lining up at 4 a.m. to see a doctor! They would wait until 6 p.m., and some would still not get seen. Each of the four doctors there would each see around 100 patients a day.

The waiting area outside the clinic.

Amos, a Kenyan doctor, has been working in Kenya and South Sudan for 20 years. He has worked with many NGOs providing aid in South Sudan. He has had planes drop bombs on him, has worked to save lives during meningitis outbreaks, saw patients during war conditions, and has just about seen it all. He was an incredible resource to have on the trip.

No one had seen a doctor in years, so the moms would bring all their kids in to be examined at once. This mother was in her mid-30s. The South Sudanese live such tough, brutal lives that they appeared so much older than they were. Another challenge was the mothers would tell us that their children were having fevers, headaches, and myalgias. I’m sure that they did because of the extreme conditions and lack of basic human necessities, but malaria was endemic in the region and also presents similarly. It was difficult to tell which kids were there simply to be checked and which actually had serious pathology.

Typical reactions when seeing the scary bearded white doctor!

A couple of the orphans helped me translate throughout the day. These kids were trained in the orphanage to speak English, Arabic, and local dialects in addition to math, science, and their other classes. They were fantastic.

It’s difficult to tell from this picture, but the thermometer says 106°. The ambient temperature would cause the thermometer to climb so high that every time I wanted to check a patient’s temperature I had to shake it to get the mercury below 98.6.

This was on our last day. We gave an address to the children, thanking them for their hospitality and allowing us to come visit them.

Most of the team on our last day.

Thank you to all the folks who helped and supported me through this experience!

Dr. Skaggs was raised in Africa. He attended the University of South Carolina School of Medicine, and was a member of the graduating class of 2013 at Palmetto Health.

Thomas Cook, MD The emergency medicine residents at Palmetto Health Richland in Columbia, SC, under the direction of program director Thomas Cook, MD, relate their experiences on global health rotations in places such as India, Nepal, Kenya, Ghana, Samoa, Korea, and China. These reports provide unique insights into why the next generation of emergency physicians will know more about the world and global health than ever before.